Why We’re Not Getting All the Medical Care We Need

By John C. Goodman.

"Even though the United States has the most expensive health care system in the world, we actually have fewer doctors than we need. The average wait to see a new doctor in this country is 3½ weeks. At the worst-performing hospitals, one in ten visitors to the emergency room leave without ever receiving medical attention—apparently because they get tired of waiting.

The situation is especially dire in rural areas. More than a third of rural hospitals are at risk of closing. Of those that are open, more than half have stopped offering labor and delivery services to pregnant women. Rural residents are more likely to die earlier than their urban counterparts from such illnesses as heart disease, cancer and stroke.

We have fewer doctors per capita than most other developed countries, and they are seeing patients less often. Between 2007 and 2017 the number of doctor visits per capita in the U.S. declined by 20 percent. Yet this was a period in which the population was aging (and presumably experiencing more medical needs) and in which Obamacare was insuring more people.

Nurse Practitioners

One solution to this problem is to let nurses practice to the full scope of their training. A majority of states now do that. But 14 put restrictions on independent practice and 11 do not allow it at all. There is no good reason to deny nurses the right to do what they have been trained to do.

The American Association of Nurse Practitioners publishes a list of studies that support the quality of nurse practitioner-led care. In a study for the Cato Institute, Dr. Jeffrey A. Singer and Spencer Pratt have identified some more recent ones. Even the American Medical Association admits that nurses can provide services within their level of training comparable to the care that physicians provide.

Lack of independence is costly and creates bureaucratic obstacles to meeting patient needs. Texas is one of the states that require a doctor supervisor for virtually everything that nurses do—despite having a large and under-doctored rural population. This means that a nurse practitioner in quasi-independent practice must find a doctor to engage in monthly supervision of her work. That can mean having to pay the doctor as much as $50,000 a year.

Not only is this very expensive, but if the doctor decides to quit supervising the nurse must find a new doctor willing to take over. In the meantime, the nurse’s patients are without medical care.

The need for a doctor supervisor almost guarantees that nurse practitioners must locate where doctors are located—and that tends to be in large cities. At a minimum we should allow nurses who relocate to under-doctored areas to pocket the $50,000 they were giving to their supervisors.

Another reason to free the nurses is to provide care for low-income patients. In the most thorough study ever done of the effects of Medicaid on patient care, researchers discovered that new enrollees increased their use of the emergency room by 40 percent. This is a wasteful way to deliver care that in most cases does not require a hospital setting.

If nurses were not required to pay high fees to a supervising doctor, they could afford to charge lower fees to low-income patients and maybe establish a practice that caters to Medicaid enrollees.

Care delivered by nurses is cheaper for everyone. In general, care provided by nurses staffing retail clinics costs 30 percent less than the same care provided in a doctor’s office.

Foreign-Trained Doctors

Another solution is to expand opportunities for doctors trained in other countries. Doctors licensed abroad who have years of training and experience cannot practice in the United States without repeating a multi-year post-med school residency training program. As a result, many foreign-trained doctors living in the United States are doing things other than practicing medicine.

As long as international licensing meets or exceeds U.S. standards, why not allow those doctors to practice without having to repeat a residency program?

Last year, Tennessee became the first state to make it easier for competent and experienced doctors in other countries who migrate to the United States to provide care to its residents. Beginning in 2025, Tennessee will grant provisional licenses to international medical graduates who have full licenses in good standing in other countries and who pass the same standardized medical exams that U.S. medical graduates must pass. After two years of supervision by a Tennessee-licensed physician, they can receive unrestricted licenses.

Similar legislation is being enacted this year in Florida, Virginia, Wisconsin and Idaho.

Medical School Graduates without Residencies

A third needed reform is to make use of medical school graduates who fail to obtain a residency (about 7% of MDs and 10% of osteopaths). Cato institute scholars Dr. Jeffrey Singer and Spencer Pratt write:

The graduates are stuck in limbo, unable to apply the knowledge and clinical skills acquired with their doctorate degrees to care for patients while also being unable to further hone and develop those clinical skills with postgraduate training.

One option that some states are adopting is to allow medical school graduates who have yet to complete a residency program to become assistant physicians (APs) and provide primary care services. However, there are many government-imposed restrictions and barriers that impede these graduates from becoming APs.

In 2014, Missouri enacted a law that permits APs to practice primary care in rural and underserved areas of the state with limited supervision by a licensed physician, with whom they must have signed a collaborative practice agreement. Six other states have subsequently passed similar laws: Arkansas, Kansas, Utah, Arizona, Louisiana, and most recently, Idaho.

Allowing competent professionals to deliver needed health care services they are trained to provide is just common sense."